Provider Demographics
NPI:1801962436
Name:MAR CO DENTAL PC
Entity type:Organization
Organization Name:MAR CO DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERNOMERDIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-972-1644
Mailing Address - Street 1:219 WHITMAN DR
Mailing Address - Street 2:MAR CO DENTAL PC
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234
Mailing Address - Country:US
Mailing Address - Phone:718-972-1644
Mailing Address - Fax:718-871-6368
Practice Address - Street 1:401 DITMAS AVE
Practice Address - Street 2:MEDICAL DENTAL PLAZA
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218
Practice Address - Country:US
Practice Address - Phone:718-972-1644
Practice Address - Fax:718-871-6368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAR CO DENTAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-27
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0382641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00823703Medicaid